Comparing Rates of Polycythemia in Hypogonadal Men Using Nasal Testosterone Gel Versus Intramuscular Testosterone: Update of a Randomized Clinical Trial.

Men with hypogonadism who use intranasal testosterone are less likely to develop polycythemia than men using intramuscular testosterone cypionate.

Does Varicocele Treatment in Adolescence Improve Fertility Outcomes in Adulthood?

Many questions on diagnosis of varicocele in adolescent patients have yet to be adequately answered, particularly regarding paternity outcomes after treated in comparison to conservative monitoring. There have been some promising outcomes after surgical treatment, particularly microsurgical varicocelectomy, but the results are mixed and may not be comparable because of differing variables. Future studies with robust methodologies are needed to identify which adolescents require treatment and when treatment should be initiated to avoid any detrimental effects on future fertility.

Medical Treatment of Hypogonadism in Men.

Urologists may commonly diagnose hypogonadism in adult men experiencing an age-related decline in serum testosterone. Low serum testosterone in conjunction with symptoms such as decreased libido, fatigue, memory deficit, or decreased vitality is described as testosterone deficiency syndrome. There are numerous therapeutic options, although each is unique in its formulation, administration, and side-effect profile. For this reason, treatment can prove to be challenging for each unique patient case. The clinician must carefully monitor key serum markers before and during treatment. With careful dosing and monitoring, therapeutic benefit can be achieved reliably and sustainably.

Testosterone replacement therapy and erectile dysfunction.

Testosterone (T) deficiency and erectile dysfunction (ED) are independently functionally and socially impairing, and their concurrence in men can be challenging to treat. Successful management requires an understanding of the mechanisms through which T underlies normal erectile function. While the literature elucidating some of these mechanisms is vast (e.g., androgen regulation of the activity of nitric oxygen synthase and phosphodiesterase type 5) for others it is scarce (e.g., catalysts of castration-induced corporal fibrosis). The randomized controlled trial data for the efficacy of T replacement as mono- or combination therapy to treat ED has been conflicting. Positive results were frequently not clinically meaningful. Meta-analyses have been helpful in illuminating trends that seem to be promising. Consensus is still lacking in several areas, such as the threshold of low T severity for which replacement therapy is most beneficial; the timing for initiating combination therapy; and the duration of treatment.

Management of male sexual dysfunction after cancer treatment.

BACKGROUND: With an increase in the number of cancer survivors each year, male sexual dysfunction becomes an important topic for discussion between patients and providers who treat cancer. The aim of this article is to review types and mechanisms of sexual dysfunction after cancer therapy and discuss treatment options. METHODS: Contemporary concepts regarding male sexual dysfunction after cancer treatment are reviewed and translated for clinical utility. FINDINGS: To optimize recovery of erectile capacity after erectile dysfunction causing cancer treatments, a penile rehabilitation protocol involving phosphodiesterase inhibitors, vacuum erection device, intra corporal injections, or a combination is likely to provide some degree of clinically significant benefit. Treating hypogonadism post cancer treatment depends on the type of cancer that has been treated and patient comorbidities. Anejaculation after cancer treatments is typically not successfully or reliably treated due to the mechanism and severity of sympathetic nerve injury. Semen cryopreservation prior to cancer treatments that may injure nerve fibers essential for the ejaculatory response is highly recommended. CONCLUSION: Management of post cancer treatment sexual dysfunction requires identification of this problem and referral to a specialist if necessary. There are several management options available that can greatly enhance quality of life in this often overlooked aspect of post cancer treatment care.

Best practices for infection prevention in penile prosthesis surgery.

PURPOSE OF REVIEW: In this review, we synthesize the most current data on strategies for the prevention and reduction of infections in men undergoing penile prosthesis surgery. We highlight important strategies for preventing infections along every step from patient selection, to the preoperative, intraoperative and postoperative states. RECENT FINDINGS: Over the last decade, significant advances have been made to help minimize penile implant infections, with the most impactful likely being the introduction of antibiotic coated penile implants. Although this has led to infection rates lower than 0.5% being reported in some series, it appears that more virulent organisms are causing a larger share of infections. SUMMARY: The change in the microbiology and persistent occurrence of penile implant infections challenges us to develop strategies to target these organisms by using novel antibiotic mixes for irrigation, dips and implant coatings. Equally important is the continual search to identify patient risk factors for the development of infections and the further optimization of the use of oral and intravenous antibiotics. It is likely we will find inspiration by looking at nonurological surgical specialties where implantation of permanent devices is routine.

Phase II Randomized, Clinical Trial Evaluating 2 Schedules of Low-Intensity Shockwave Therapy for the Treatment of Erectile Dysfunction.

PURPOSE: To evaluate safety and clinical response of Low-intensity Shockwave Therapy (Li-SWT) for the treatment of erectile dysfunction. MATERIALS & METHODS: A single-institution, 2 arm, phase II randomized clinical trial was conducted between February 2017 and April 2019. Patients were randomized into 2 groups, with Li-SWT delivering a total of 3,600 shocks over 5 days (720 once a day, Group A) or over 2 weeks (600 once a day, 3 times a week, Group B). Patients were evaluated for the safety of therapy and completed the International Index of Erectile Function-Erectile Function domain and the Erectile Hardness Scale assessment at baseline, and at 1, 3, and 6 months visits. RESULTS: Among 87 evaluable patients, 45 and 42 were allocated to Groups A and B treatment schedules, respectively, and 80 patients (40 per group) completed the 6-month evaluation. No adverse events were reported during treatment or during follow-up. There were statistically significant (P < .05) improvements in International Index of Erectile Function-Erectile Function score (mean increase of 2.7 [95% CI = 1.2, 4.2] and 2.7 points [95% CI = 1.4, 4.1] for Groups A and B, respectively) and in Erectile Hardness Scale (mean increase of 0.6 points (95% CI = 0.3, 0.8) and 0.5 (95% CI = 0.2, 0.8) for Groups A and B, respectively) at 6 months, with no differences between groups. CONCLUSION: No difference in outcomes was found when Li-SWT 3,600 shocks were delivered over 1 or 2 weeks at 6 months follow-up and both schedules were safe with no adverse events during or after treatment. Further trials with longer follow-up and sham arm will provide valuable information regarding treatment efficacy and durability. Patel P, Katz J, Lokeshwar SD, et al. Phase II Randomized, Clinical Trial Evaluating 2 Schedules of Low-Intensity Shockwave Therapy for the Treatment of Erectile Dysfunction. Sex Med 2020;8:214-222.

The Basic Physics of Waves, Soundwaves, and Shockwaves for Erectile Dysfunction.

INTRODUCTION: Over the past decade, low-intensity extracorporeal shockwave therapy (Li-ESWT) has emerged as a treatment modality for erectile dysfunction (ED). To better appreciate the differences between the various devices for the treatment of ED, it is imperative for physicians to understand the underlying physics of the different shockwave generators. AIM: In this article, we explain the physics of shockwaves by establishing a foundation regarding the basics of waves, specifically soundwaves. We also describe the different shockwave generators available and assess their potential clinical utility. METHODS: We reviewed basic principles of wave propagation, randomized controlled trials investigating Li-ESWT for ED and other medical diseases, and individual industry shockwave generator websites, in order to describe the basic physics underlying Li-ESWT. MAIN OUTCOME MEASURE: We primarily aimed to describe the physics underlying shockwave generators and to provide a framework for understanding the relevant subtypes and adjustable parameters. RESULTS: A wave is a disturbance in a medium that transports energy without permanently transporting matter. In shockwaves, a soundwave is generated with a speed faster than the local speed of sound. Shockwaves are classically generated by three different types of energy sources: electrohydraulic, electromagnetic, or piezoelectric, which all create a shockwave through the conversion of electric potential energy to mechanical energy. Importantly, radial pressure waves do not behave the same as conventional shockwaves and are more like "ordinary" sound waves in that they achieve a significantly lower peak pressure, a slower rise time, and propagate outwards without a focal point. CLINICAL IMPLICATIONS: Li-ESWT is not currently approved by the U.S. Food and Drug Administration and is considered investigational in the United States. However, it is currently available to patients under clinical trial protocols and it is important to understand the basic physics of shockwaves to understand the differences between the different shockwave devices. STRENGTH & LIMITATIONS: This is a comprehensive review of the physics underlying Li-ESWT but only tangentially explores the biological impact of shockwaves. CONCLUSION: Physicians currently using or those contemplating purchasing a Li-ESWT device should understand the basic physics underlying the device, as well as which treatment protocols were used to demonstrate clinical efficacy in treating ED. Katz JE, Clavijo RI, Rizk P, et al. The Basic Physics of Waves, Soundwaves, and Shockwaves for Erectile Dysfunction. Sex Med Rev 2020;8:100-105.

A Novel Video-Based Patient Education Program to Reduce Penile Prosthetic Surgery Cancellations.

Penile prosthetic surgery is an effective treatment for men with erectile dysfunction. Cancellation of surgery is disruptive and costly to patients, physicians, and the healthcare system. This pilot study sought to analyze surgery cancellations and implement a video-based patient education program to decrease surgery noncompletion. Baseline penile prosthetic surgery completion, rescheduling, and cancellation rates among consecutively scheduled surgeries were determined using a national cohort. Selected prosthetic surgeons then implemented Vidscrip, a video-based patient education program. Prerecorded videos were delivered via text message 14 days, 7 days, and 1 day preoperatively, as well as 1 day postoperatively. Subsequent analysis determined noncompletion rates, reasons for noncompletion, surgeon volume, and video utilization. Two-hundred twenty-six surgeries were scheduled in the baseline cohort; 141 were completed, and 85 were rescheduled or canceled. Among the intervention cohort, 290 patients completed, 7 rescheduled, and 37 canceled surgery. After program implementation, the surgery noncompletion rate was reduced compared to baseline (13.2% vs. 37.6%, p < .05), corresponding to a number needed to treat of 4.1. When stratified by surgeon volume, there was no difference in noncompletion rate (>20 cases vs. ≤20 cases: 8.20% vs. 32.0%, p = .35). Video utilization was widely variable among practices (median viewing time 58.6 min, IQR 5.09-113). Penile prosthetic surgery is frequently rescheduled or canceled. Implementing a video-based patient education program reduces surgery noncompletion, improving efficiency and quality of care. Wider implementation is needed to validate these findings, while cost-effectiveness analyses may further support their broad adoption.

Update on male reproductive endocrinology.

Practitioners of male reproductive and sexual medicine must have an intimate understanding of the physiology of male reproductive endocrinology, as such a knowledge is the cornerstone on which hormonal treatments are based. In this review, we highlight what is known about male reproductive endocrine physiology and the various control mechanisms for the system. We also discuss the limitations of our current understanding of the reproductive physiology. We hope that this review is helpful for male reproductive medicine practitioners in understanding the principles on which hormonal treatments are based.

Adverse Effects of Cannabis on Male Reproduction.

The use of cannabis use is likely to increase as regulations on its consumption are diminishing throughout the world. Coinciding with an increase in the use of cannabis is an observation that semen quality appears to be declining in developed countries, and couples are delaying conception more often than previous generations. Therefore, it is important to study the effects of cannabis on male reproductive potential in order to better counsel infertile couples and men of reproductive age. In this mini-review, we highlight the known effects of cannabis on clinical markers of male fertility potential and review the role of the endocannabinoid system as it pertains to sex hormone and sperm production, as well as sperm function. Overall, current evidence is contradictory regarding the effects of cannabis on male reproductive hormone production. However, most studies associate cannabis use with lower sperm concentrations, suggesting a negative impact on fertility potential.

A Phase 2 Randomized Trial To Evaluate Different Dose Regimens of Low-intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: Clinical Trial Update.

Preliminary results from our study provide further evidence that low-intensity extracorporeal shockwave therapy is a safe and effective treatment modality for erectile dysfunction. Our treatment protocol with shockwaves given to men over 2 wk had the most robust effect.

Whole Exome Sequencing of a Consanguineous Turkish Family Identifies a Mutation in GTF2H3 in Brothers With Spermatogenic Failure.

In this case report we describe our investigation into the genetic cause of infertility due to idiopathic nonobstructive azoospermia in a consanguineous Turkish family. We extracted DNA from blood and applied whole exome sequencing on 4 infertile brothers in this family diagnosed with oligo- and azoospermia. Standard bioinformatics analysis pipelines were run including alignment to the reference genome, variant calling, and quality control filtering. Potentially pathogenic variants were identified and prioritized using genetic variant annotation software and public variant frequency databases, followed by validation with Sanger sequencing. A nonsynonymous variant in "general transcription factor TFIIH subunit 3" (GTF2H3) was identified in this consanguineous family. This variant in chromosome 12 (12chr: 124144111 T>C, p.Ser222Pro) of GTF2H3 represents a likely a disease-causing mutation as it is predicted to be damaging, rare, segregates with the disease, and is highly evolutionarily conserved. Familial segregation analysis of the variant showed that it was present as a homozygous mutation in the brothers with nonobstructive azoospermia, and heterozygous mutation in the oligospermic brothers. We propose a mechanism by which this variant leads to deficits in Vitamin A signaling, which is essential for spermatogenesis.

Policy on Posthumous Sperm Retrieval: Survey of 75 Major Academic Medical Centers.

OBJECTIVE: To evaluate the presence and content of policies on posthumous sperm retrieval at 75 major academic medical centers in the U.S. MATERIALS AND METHODS: We surveyed the top 75 major academic medical centers ranked for research in 2016 by U.S. News & World Report using a questionnaire-based telephone/web survey. We gathered data on the presence and content of posthumous sperm retrieval policies on the Internet. If not published, we contacted the legal counsel, the ethics and compliance offices, the urology department, as well as the infertility treatment center associated with each institution. In addition, we also surveyed members of the Society for Male Reproduction and Urology. RESULTS: We gathered data regarding posthumous sperm retrieval from 41 out of the 75 major academic medical centers. Of the 41 institutions, only 11 (26.8%) had policies regarding posthumous sperm retrieval. Out of those 11 centers, 4 required prior written consent, whereas the remaining 6 allowed for verbal or inferred consent from the surviving life partner. One policy prohibited the procedure. Five of the policies in this survey included a bereavement period. Of the 30 (73.2%) centers without policies, lack of legal guidance was cited as the most common barrier to policy adoption. CONCLUSION: Only a small proportion of major academic medical centers have policies on posthumous sperm retrieval. Medical centers can adopt individualized policies based on guidelines published by professional societies.

Three-piece Penile Prosthesis Implantation in Refractory Ischemic Priapism-Tips and Tricks.

INTRODUCTION AND OBJECTIVES: Implantation of a penile prosthesis in a patient with significant corporal fibrosis can pose a significant challenge to the surgeon, necessitating the knowledge of specific techniques used to dilate and close aggressively scarred corpora. The objective of our instructional video is to discuss 2 techniques used to approach corporal fibrosis: proper and safe use of cavernotomes for dilation and use of narrower prostheses. METHODS: In this video, we present a 53-year-old man with a history of priapism 3 years ago that lasted 4 days in the setting of trazodone use. He was managed with corporal irrigation and subsequently developed severe erectile dysfunction. Notably, the patient had a history of sickle cell anemia, and on physical examination was noted to have densely fibrotic corpora. After extensive counseling regarding options, he chose a penile implant. The surgical was planned using the "no touch technique." After the corporotomies were made, we began dilating the corpora. Hegar dilators and Dilamezinsert were attempted at first but met significant resistance. We switched to cutting cavernotomes and were able to dilate up to 11-Fr distally and up to 13-Fr proximally. The proper use of cavernotomes is highlighted in our video, with care being taken to aim the cutting edge of the cavernotome laterally away from the urethra. We also used the narrowest inflatable prosthesis available to us (Coloplast Titan narrow-base) and describe the narrower devices available in inflatable and malleable forms as an option for less-than-ideally dilated corpora. The pump and reservoir placement was completed uneventfully. RESULTS: The patient was admitted overnight for observation and check of a complete blood count given his history of sickle cell anemia. He was able to be discharged after 23 hours of observation. The patient presented to the clinic 4 weeks later for pump activation. He was able to achieve good rigidity and had a penile length adequate for penetration after maximal activation. CONCLUSION: This video discusses the approach to penile prosthesis placement in patients with significant corporal fibrosis. It highlights the proper use of cutting cavernotomes and the availability of narrow-diameter prostheses, both malleable and inflatable.